How Will Act 62 Affect YOU?

By: Luciana Randall
Apr 1, 2009

      The Autism Society of America, Pittsburgh hosted two informational meetings featuring speaker Cindy Fillman, Director of the Office of Insurance Consumer Liaison, during the week of  February 9th.  Ms. Fillman presented details about Act 62, and responded to a wide variety of questions from parents and professionals in attendance.             

     There are many issues still on the table, so not all questions have clear-cut answers at this time.   For more information, please contact the Insurance Consumer Liaison at 717.783.2011.  They also would like to hear about your specific situation and what your concerns are if your child is covered under the Act.  You may also send email to ra-in-autism@state.pa.us.  If you see a potential wrinkle in your child’s coverage or services, and communicate this to the Department, it may help them write better regulations to avoid problems similar to the ones you anticipate.           

     The following is a synopsis of some facts, and some commonly asked questions:           

     Children under 21 years of age who are covered by a large group employer (51 employees and up,) OR who are on CHIP or AdultBasic are covered by this mandate.  Coverage limits are $36,000 per year in diagnostic and treatment costs with no limit on the number of diagnostic/treatment visits until the cap is reached, and coverage is subject to co-pays, deductibles and coinsurance, similar to how other medical services are covered.           

     Co-pays are reimbursable by MA for those children already enrolled in MA, but only up to the MA rate for that service.  So if the private insurance pays $40 for one hour of service, and the co-pay is $15 on a service with an MA rate of $55, that co-pay would be covered (as 40 +15 =55, the MA rate.)  But if the MA rate for that service was only 50$, MA would only reimburse $10 of that co-pay.It is important to note that if you have a plan with a deductible, that must be met.  MA will not reimburse these costs.  Families will need to budget annually to include paying for services up to the deductible amount before coverage kicks in.

     Treatment requirements are as follows:            

*  Must be medically necessary (and EACH insurer, as the law is currently written, will define medical necessity themselves;)           

*  Must be identified in a treatment plan;           

*  Must be ordered or prescribed by a licensed provider (this includes licensed physicians, physician assistants, psychologists, clinical social workers, certified registered nurse practitioners, and those who work under their direction;)           

* Service providers who are enrolled in the MA program as of July 9,2008, can be grandfathered.Covered Services and treatments:           

 *  Diagnostic assessment of  autism spectrum disorders;           

*  Treatment of autism spectrum disorders;           

*  Prescription medications and blood level tests;           

*  Services of a psychiatrist/psychologist;           

*  Applied Behavioral Analysis;           

*  Other “rehabilitative care;”           

*  Therapies (speech, physical, occupational therapy.)

Frequently asked questions:           

1.  What about Summer Therapeutic Activity Programs?   Since private insurers are not lifting services and descriptions directly from MA, (they can pick and choose some covered services,) it is possible that STAP’s may not be covered.  If your plan enrollment date is January 1st, this will not affect you this summer, 2009, but it could affect you summer, 2010.  If your plan enrollment date is the far less common July 1, this may affect you this coming summer.             

2.  Will insurance companies be able to deny services if my child is not making “sufficient progress” or has reached a plateau in his or her progress?  No.  The law specifically requires coverage of services intended to produce progress as well as those intended to prevent regression.  

3.  What if an insurance company denies a claim for my child’s services?  Act 62 requires that the insurance company provides an expedited review process for appeals of denied claims.  If the insurance company upholds the denial, Act 62 provides for a secondary expedited review process to be administered by the Insurance Department.  If the denial is still upheld, that decision may be challenged in court.           

4.  Is Case Management covered?  No.           

5.  What’s this I hear about Behavior Specialist Licensing?  Regulations are being developed pertaining to the licensing of behavior specialists providing services to children with autism.  Is is anticipated this process will be complete sometime in 2012.  Until then, a BSC’s who provide treatment pursuant to a treatment plan fit within the definition of “autism service proficer” until one year after the licensure regulations are published, or July 9, 2011, whichever is later.  Until then, “grandfathered” BSC’s may provide treatment under Act 62, however insurers may require providers to participate in their networks as a condition of payment.           

PLEASE READ YOUR INSURANCE CONTRACT, and discuss your needs with your human resource director.  Contracts are specific to each employer, so it is possible you can get specific coverage if you request it.